<p> UNIVERSITY OF CALIFORNIA, SAN DIEGO MEDICAL EVALUATION QUESTIONNAIRE FOR RESPIRATOR-USE CERTIFICATION</p><p>Name: ______Date: ______DOB: ______Job Title: ______Sex: M/F Age: ______Height: ______ft______in Weight: ______Phone #: ______Best Time to Call at this #: ______This questionnaire will be reviewed by a health care professional at the UCSD Occupational/Environmental Medicine Department (619-471-9210). Check the type of respirator you will use (you can check more than one category): a. _____N, R, or P disposable filtering face piece (filter-mask, non-cartridge type) b. _____Air purifying cartridge (i.e., half- or full-facepiece, powered-air-purifying) c. ______Air supplied (i.e., air-line, self-contained breathing apparatus)</p><p>Have you worn a respirator: Yes/No If “yes,” what type(s)______1. Do you currently smoke tobacco, or have you smoked tobacco in the last month: Yes/No</p><p>2. Have you ever had any of the following medical conditions? If YES, how long have you had the condition? (Please give a brief explanation on the dotted lines below.) a. Seizures...... Yes / No b. Diabetes...... Yes / No c. Allergic reactions that interfere with your breathing...... Yes / No d. Claustrophobia...... Yes / No e. Troubling smelling odors...... Yes / No</p><p>3. Have you ever had any of the following pulmonary or lung problems? If YES, how long have you had the problem? (Please give a brief explanation on the dotted lines below.) a. Asbestosis...... Yes / No b. Asthma...... Yes / No c. Chronic bronchitis...... Yes / No d. Emphysema...... Yes / No e. Pneumonia...... Yes / No f. Tuberculosis...... Yes / No g. Silicosis...... Yes / No h. Pneumothorax (Collapsed lung)...... Yes / No i. Lung cancer...... Yes / No j. Broken ribs...... Yes / No k. Any injuries or surgeries to the chest...... Yes / No l. Any other lung conditions (that you have been told about)...... Yes / No</p><p>D:\Docs\2017-12-14\0806d8674c9636da0353c0441da26c50.doc 4. Do you currently have any of the following symptoms of pulmonary or lung illness? If YES, how long have you had the illness? (Please give a brief explanation on the dotted lines below.) a. Shortness of breath Wwhile at rest...... Yes / No b. Shortness of breath while walking fast, walking up a slight incline or hill...... Yes / No c. Shortness of breath while walking with other people at an ordinary pace on level ground...... Yes / No d. Shortness of breath while doing everyday-type activities...... Yes / No e. Shortness of breath that interferes with your job...... Yes / No f. Coughing that produces phlegm...... Yes / No g. Coughing up blood in the last month...... Yes / No h. Coughing that occurs mostly while you lie down...... Yes / No i. Coughing that wakes you early in the morning...... Yes / No j. Chest pains when you breathe deeply...... Yes / No k. Any wheezing...... Yes / No l. Wheezing that interferes with your job...... Yes / No m. Do you ever have to stop for a breath while walking on level ground...... Yes / No n. Do you have any other symptoms related to lung problems...... Yes / No</p><p>5. Have you ever had any of the following cardiovascular or heart problems? If YES, how long have you had the problem? (Please give a brief explanation on the dotted lines below.) a. Heart attack...... Yes / No b. Irregular heart beat (arrhythmia)...... Yes / No c. Stroke...... Yes / No d. Angina (chest pain)...... Yes / No e. Heart Failure...... Yes / No f. Swelling of the legs or feet...... Yes / No g. High blood pressure...... Yes / No h. Any other heart problems...... Yes / No</p><p>6. Have you ever had any of the following cardiovascular or heart symptoms? If YES, how long have you had these symptoms? (Please give a brief explanation on the dotted lines below.) a. Frequent tightness or pain in the chest...... Yes / No b. Pain or tightness in the chest during physical activity...... Yes / No c. Pain or tightness in the chest that interferes with your job...... Yes / No d. Have you noticed your heart skipping or missing beats...... Yes / No D:\Docs\2017-12-14\0806d8674c9636da0353c0441da26c50.doc d. Heartburn or indigestion not related to eating...... Yes / No e. Other symptoms that you think might be related to the heart...... Yes / No</p><p>7. Do you currently take medication for any of the following problems? If YES, how long have you been taking these medications? (Please give a brief explanation on the dotted lines below.) a. Breathing or lung problems...... Yes / No b. Heart trouble...... Yes / No c. High blood pressure...... Yes / No d. Seizures (fits)...... Yes / No</p><p>8. While wearing a respirator, have you ever had any of the following problems? (Skip these if you haven’t worn a respirator before.) If YES, how long have you had these problems? (Please give a brief explanation on the dotted lines below.) a. Eye irritations...... Yes / No b. Skin allergies or rashes...... Yes / No c. Anxiety...... Yes / No d. General weakness or fatigue (tiredness)...... Yes / No e. Any other problems that interfere with use of your respirator...... Yes / No</p><p>9. Do you know how to contact the UCSD Occupational/Environmental Medicine Department health care professional who will review this questionnaire?...... Yes / No</p><p>10. Would you like to talk to the health care professional who will review your answers on this questionnaire?...... Yes / No</p><p>I agree that I have answered the above questions to the best of my knowledge.</p><p>Employee’s signature: ______Date: ______</p><p>Reviewed by: ______Date: ______</p><p>Comments:</p><p>Referred by UCSD Environment, Health & Safety Office Industrial Hygiene, Mail Code 0958, 09/21/04</p><p>D:\Docs\2017-12-14\0806d8674c9636da0353c0441da26c50.doc You only have to answer the following questions if you will be wearing a full face piece respirator (either air supplied or air purifying) ,or a self-contained breathing apparatus (SCBA). Otherwise, you may choose to skip the remaining questions.</p><p>15. Have you ever had (now or before) any of the following? If YES, how long have you had these problems? (Please give a brief explanation on the dotted lines below.) a. Loss of vision in either eye (temporarily or permanently)...... Yes / No b. Wear contact lenses...... Yes / No c. Wear glasses (spectacles)...... Yes / No d. Color blindness...... Yes / No e. Any other vision problems...... Yes / No</p><p>16. Have you ever had (now or before) any of the following? If YES, how long have you had these problems? (Please give a brief explanation on the dotted lines below.)</p><p> a. Injury to the ears, including a broken ear drum...... Yes / No b. Difficulty hearing...... Yes / No c. A hearing aid...... Yes / No d. Any other hearing problem...... Yes / No</p><p>17. Have you ever had (now or before) any of the following? If YES, how long have you had these problems? (Please give a brief explanation on the dotted lines below.) a. Back injury or back pain...... Yes / No b. Weakness in the arms, hands, legs, or feet...... Yes / No c. Difficulty moving arms and / or legs...... Yes / No d. Pain or stiffness when you lean backward or forward at the waist...... Yes / No e. Difficulty fully moving the head up or down, or side to side...... Yes / No f. Difficulty bending at the knees or squatting to the ground...... Yes / No g. Difficulty climbing stairs or ladders while carrying greater than 25 pounds...... Yes / No h. Other muscle-skeletal problems that interferes with using a respirator...... Yes / No</p><p>Employee initials: ______Referred by UCSD Environment, Health & Safety Office Industrial Hygiene, Mail Code 0958, 09/21/04</p><p>D:\Docs\2017-12-14\0806d8674c9636da0353c0441da26c50.doc</p>